Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

For the first time since leaving medical school, many doctors are having to take tests to renew board certification in their fields — 147 specialties from dermatology to obstetrics.

Any doctor can deliver a baby, treat cancer, or declare himself a cardiologist. Certification means the doctor had special training in that field and passed an exam to prove knowledge of it.

They used to do this once and be certified for life. That changed in the 1990s — doctors certified since then must retest every six to 10 years to prove their skills haven't gone stale.

For some specialists, like the doctors who push tubes into heart arteries to unclog blockages, this is the first year many are going through retesting.

Older doctors also are feeling the heat. More than a quarter of a million of them were "grandfathered" with lifetime certificates, but are being urged to retest voluntarily to show they still know their stuff.

Most don't want to do this. One who isn't grumbling is Dr. Stephen Mester, 52, a cardiologist at Brandon Regional Hospital in Brandon, Fla.

"I am choosing to renew. It's just an opportunity to maintain my skills and confirm to myself that I can do what I've been trained to do," he said. "Most of what I do today didn't exist, and some of it not even thought of, when I was in medical school."

The recent American College of Cardiology conference in Atlanta offered refresher sessions to help doctors prepare. In one, they played "name that tune," listening to tapes to identify various heart murmurs.

In another, they played "beat the clock" to do an artery-opening procedure within 90 minutes of a mock patient arriving at a hospital. This session, which Mester took, was led by Dr. William Hamman, a Michigan cardiologist and United Airlines pilot.

"As an airline captain, everything I do is performance-based," with frequent testing on simulators of landings, takeoffs and other skills, Hamman said.

Yet most airline accidents are caused by breakdowns in softer skills — communication and teamwork, he said. "Health care has not even touched that subject" in testing proficiency, he complained.

Many docs think they know more than they do
Research shows that what doctors think they know does not match what they do, and that performance declines with years in practice, two members of the American Board of Internal Medicine wrote recently in the New England Journal of Medicine.

The authors of an opposing essay — a medical school dean, a professor who teaches primary care, and a practicing physician — complain that testing emphasizes recall of facts rather than making full use of available sources of information, such as electronic references and the Internet, as modern doctors are taught to do.

The recertification tests are a work in progress. In the future, some boards plan to include assessment of a doctor's communication skills with patients. Eventually, testing may include rating a doctor's technical skills and directly observing performance, said the cardiology college's chief education officer, Joseph Green.

Dr. Michael Ring, a 53-year-old cardiologist from Providence Sacred Heart Medical Center in Spokane, Wash., put himself through this voluntarily in a training exercise at the Atlanta conference.

The people who really know how well a doctor performs are the nurses and other members of the team, Ring said. "If there was a way they could grade you without penalty to their careers," that would be best, he said.

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